Changing Patterns in Place of Cancer Death in England: A Population-Based Study

Background

Most patients with cancer prefer to die at home or in a hospice, but hospitals remain the most common place of death (PoD).This study aims to explore the changing time trends of PoD and the associated factors, which are essential for end-of-life care improvement.

Methods and Findings

The study analysed all cancer deaths in England collected by the Office for National Statistics during 1993–2010 (n = 2,281,223). Time trends of age- and gender-standardised proportion of deaths in individual PoDs were evaluated using weighted piecewise linear regression. Variables associated with PoD (home or hospice versus hospital) were determined using proportion ratio (PR) derived from the log-binomial regression, adjusting for clustering effects. Hospital remained the most common PoD throughout the study period (48.0%; 95% CI 47.9%–48.0%), followed by home (24.5%; 95% CI 24.4%–24.5%), and hospice (16.4%; 95% CI 16.3%–16.4%). Home and hospice deaths increased since 2005 (0.87%; 95% CI 0.74%–0.99%/year, 0.24%; 95% CI 0.17%–0.32%/year, respectively, p<0.001), while hospital deaths declined (−1.20%; 95% CI −1.41 to −0.99/year, p<0.001). Patients who died from haematological cancer (PRs 0.46–0.52), who were single, widowed, or divorced (PRs 0.75–0.88), and aged over 75 (PRs 0.81–0.84 for 75–84; 0.66–0.72 for 85+) were less likely to die in home or hospice (p<0.001; reference groups: colorectal cancer, married, age 25–54). There was little improvement in patients with lung cancer of dying in home or hospice (PRs 0.87–0.88). Marital status became the second most important factor associated with PoD, after cancer type. Patients from less deprived areas (higher quintile of the deprivation index) were more likely to die at home or in a hospice than those from more deprived areas (lower quintile of the deprivation index; PRs 1.02–1.12). The analysis is limited by a lack of data on individual patients'' preferences for PoD or a clinical indication of the most appropriate PoD.

Conclusions

More efforts are needed to reduce hospital deaths. Health care facilities should be improved and enhanced to support the increased home and hospice deaths. People who are single, widowed, or divorced should be a focus for end-of-life care improvement, along with known at risk groups such as haematological cancer, lung cancer, older age, and deprivation. Please see later in the article for the Editors'' Summary     

Fracture Risk and Adjuvant Therapies in Young Breast Cancer Patients: A Population-Based Study

Background

Breast cancer survivors have an increased risk of bone fracture. But the risk among young patients with adjuvant therapies remains unknown. This population-based study is aimed to assess the incidence and risk of fracture among young (age of 20 to 39 years) breast cancer patients who received adjuvant therapies.

Methods

From January 2001 to December 2007, 5,146 newly diagnosed breast cancer patients were enrolled from the National Health Insurance Research Database (NHIRD) in Taiwan. Patients were observed for a maximum of 6 years to determine the incidence of newly onset fracture. Kaplan Meier and Cox regression analyses were used to evaluate the risk of fracture in young breast cancer patients who received adjuvant treatments.

Results

Of the total 5,146 young (age of 20 to 39 years) breast cancer patients, the Cox multivariate proportional hazards analysis showed that AIs, radiotherapy, and monoclonal antibodies were significantly associated with a high risk of fracture. Moreover, patients who received AIs for more than 180 days had a high hazard ratio (HR) of 1.77 (95% CI = 0.68–4.57), and patients who received more than four radiotherapy visits had a high HR of 2.54 (95% CI = 1.07–6.06). Under the site-specific analysis, young breast cancer patients who received AIs had the highest risk of hip fracture (HR = 8.520, 95% CI = 1.711–42.432, p < 0.04), whereas patients who received radiotherapy had the highest risk of vertebral fracture (HR = 5.512, 95% CI = 1.847–16.451, p < 0.01).

Conclusion

Young breast cancer patients who are receiving AIs, radiotherapy or monoclonal antibody need to be more careful for preventing fracture events. Breast cancer treatment plans are suggested to incorporate fracture prevention interventions.     

Surveillance and Correlation of Antimicrobial Usage and Resistance of Pseudomonas aeruginosa: A Hospital Population-Based Study

This retrospective study evaluated trends and association between resistance of Pseudomonas aeruginosa isolated from patients with hospital-acquired infections (HAIs) and hospital antimicrobial usage from 2003 through 2011 in a tertiary care hospital in northeast China. HAI was defined as occurrence of infection after hospital admission, without evidence that infection was present or incubating (≦48 h) on admission. In vitro susceptibilities were determined by disk diffusion test and susceptibility profiles were determined using zone diameter interpretive criteria, as recommended by Clinical and Laboratory Standards Institute (CLSI). Data on usage of various antimicrobial agents, expressed as defined daily dose (DDD) per 1,000 patients-days developed by WHO Anatomical Therapeutical Chemical (ATC)/DDD index 2011, were collected from hospital pharmacy computer database. Most of 747 strains of P. aeruginosa were collected from respiratory samples (201 isolates, 26.9%), blood (179, 24.0%), secretions and pus (145, 19.4%) over the years. Time series analysis demonstrated a significant increase in resistance rates of P. aeruginosa to ticarcillin/clavulanic acid, piperacillin/tazobactam, cefoperazone/sulbactam, piperacillin, imipenem, meropenem, ceftazidime, cefepime, ciprofloxacin, and levofloxacin except aminoglycosides over time in the hospital (P<0.001). The rates of carbapenem-resistant P. aeruginosa (CRPA) isolated from patients with HAIs were 14.3%, 17.1%, 21.1%, 24.6%, 37.0%, 48.8%, 56.4%, 51.2%, and 54.1% over time. A significant increase in usage of anti-pseudomonal carbapenems (P<0.001) was seen. ARIMA models demonstrated that anti-pseudomonal carbapenems usage was strongly correlated with the prevalence of imipenem and meropenem-resistant P. aeruginosa (P<0.001). Increasing of quarterly CRPA was strongly correlated at one time lag with quarterly use of anti-pseudomonal carbapenems (P<0.001). Our data demonstrated positive correlation between anti-pseudomonal antimicrobial usage and P. aeruginosa resistance to several classes of antibiotics, but not all antimicrobial agents in the hospital.     

Urban and Rural Differences of Acute Cardiovascular Disease Events: A Study from the Population-Based Real-Time Surveillance System in Zhejiang,China in 2012

Zhejiang province, China, has implemented a population based, real-time surveillance system that tracks acute cardiovascular diseases (CVDs) events since 2001. This study aimed to describe the system and report CVD incidence, mortality and case-fatality between urban and rural areas in Zhejiang in 2012. The surveillance system employs a stratified random sampling method covering all permanent residents of 30 counties/districts in Zhejiang. Acute CVD events such as coronary heart disease (CHD) and stroke were defined, registered and reviewed based on the adapted MONICA (Monitoring Trends and Determinants in Cardiovascular Disease) definitions. Data were collected from health facilities, vital registries, supplementary surveys, and additional investigations, and were checked for data quality before input in the system. We calculated the rates and compared them by gender, age and region. In 2012, the incidence, mortality and case-fatality of total acute CVD events were 367.0 (CHD 59.1, stroke 307.9), 127.1 (CHD 43.3, stroke 83.8) per 100,000 and 34.6% (CHD 73.2%, stroke 27.2%), respectively. Compared with rural areas, urban areas reported higher incidence and mortality but lower case-fatality rates for CHD (P<0.001), while lower incidence but higher mortality and case-fatality rates for stroke (P<0.001). We found significant differences on CHD and stroke epidemics between urban and rural areas in Zhejiang. Special attentions need to be given to stroke control, especially in rural areas.     

Patterns in Place of Cancer Death in the State of Qatar: A Population-Based Study

Background

International studies show that most people prefer to die at home; however, hospitals remain the most common place of death (PoD). This study aims to investigate the patterns in PoD and the associated factors, which are crucial for end-of-life cancer care enhancement.

Method

This retrospective, population-based study analyzed all registered cancer deaths in Qatar between January 1, 2006 and December 31, 2012 (n = 1,224). The main outcome measures were patient characteristics: age, gender, nationality, cancer diagnosis, year of death, and PoD. Time trends for age-standardized proportions of death in individual PoDs were evaluated using chi-square analysis. Odds ratio (OR) were determined for variables associated with the most preferred (acute palliative care unit [APCU] and hematology/oncology ward) versus least preferred (ICU and general medicine ward) PoDs in Qatar, stratified by nationality.

Results

The hematology/oncology ward was the most common PoD (32.4%; 95% CI 26.7–35.3%) followed by ICU (31.4%; 95% CI 28.7–34.3%), APCU (26.9%; 95% CI 24.3–29.6%), and general medicine ward (9.2%; 95% CI 7.6–11.1%). APCU trended upward (+0.057/year; p<0.001), while the hematology/oncology ward trended downward (−0.055/year; p<0.001). No statistically significant changes occurred in the other PoDs; home deaths remained low (0.4%; 95% Cl 0.38–0.42). Qataris who died from liver cancer (OR 0.23) and aged 65 or older (OR 0.64) were less likely to die in the APCU or hematology/oncology ward (p<0.05). Non-Qataris who died from pancreatic cancer (OR 3.12) and female (OR 2.05) were more likely to die in the APCU or hematology/oncology ward (p<0.05). Both Qataris and non-Qataris who died from hematologic malignancy (OR 0.18 and 0.41, respectively) were more likely to die in the ICU or general medicine ward (p<0.05).

Conclusion

A high percentage of cancer deaths in Qatar occur in hospital. As home was the preferred PoD for most people, effective home care and hospice programs are needed to improve end-of-life cancer care.     

Schistosoma haematobium Infection and CD4+ T-Cell Levels: A Cross-Sectional Study of Young South African Women

Schistosoma (S.) haematobium causes urogenital schistosomiasis and has been hypothesized to adversely impact HIV transmission and progression. On the other hand it has been hypothesized that HIV could influence the manifestations of schistosomiasis. In this cross-sectional study, we explored the association between urogenital S. haematobium infection and CD4 cell counts in 792 female high-school students from randomly selected schools in rural KwaZulu-Natal, South Africa. We also investigated the association between low CD4 cell counts in HIV positive women and the number of excreted schistosome eggs in urine. Sixteen percent were HIV positive and 31% had signs of urogenital schistosomiasis (as determined by genital sandy patches and / or abnormal blood vessels on ectocervix / vagina by colposcopy or presence of eggs in urine). After stratifying for HIV status, participants with and without urogenital schistosomiasis had similar CD4 cell counts. Furthermore, there was no significant difference in prevalence of urogenital schistosomiasis in HIV positive women with low and high CD4 cell counts. There was no significant difference in the number of eggs excreted in urine when comparing HIV positive and HIV negative women. Our findings indicate that urogenital schistosomiasis do not influence the number of circulating CD4 cells.     

Adverse Obstetric and Perinatal Outcomes following Treatment of Adolescent and Young Adult Cancer: A Population-Based Cohort Study

Objective

To investigate obstetric and perinatal outcomes among female survivors of adolescent and young adult (AYA) cancers and their offspring.

Methods

Using multivariate analysis of statewide linked data, outcomes of all first completed pregnancies (n = 1894) in female survivors of AYA cancer diagnosed in Western Australia during the period 1982–2007 were compared with those among females with no cancer history. Comparison pregnancies were matched by maternal age-group, parity and year of delivery.

Results

Compared with the non-cancer group, female survivors of AYA cancer had an increased risk of threatened abortion (adjusted relative risk 2.09, 95% confidence interval 1.51–2.74), gestational diabetes (2.65, 2.08–3.57), pre-eclampsia (1.32, 1.04–1.87), post-partum hemorrhage (2.83, 1.92–4.67), cesarean delivery (2.62, 2.22–3.04), and maternal postpartum hospitalization>5 days (3.01, 1.72–5.58), but no excess risk of threatened preterm delivery, antepartum hemorrhage, premature rupture of membranes, failure of labor to progress or retained placenta. Their offspring had an increased risk of premature birth (<37 weeks: 1.68, 1.21–2.08), low birth weight (<2500 g: 1.51, 1.23–2.12), fetal growth restriction (3.27, 2.45–4.56), and neonatal distress indicated by low Apgar score (<7) at 1 minute (2.83, 2.28–3.56), need for resuscitation (1.66, 1.27–2.19) or special care nursery admission (1.44, 1.13–1.78). Congenital abnormalities and perinatal deaths (intrauterine or ≤7 days of birth) were not increased among offspring of survivors.

Conclusion

Female survivors of AYA cancer have moderate excess risks of adverse obstetric and perinatal outcomes arising from subsequent pregnancies that may require additional surveillance or intervention.     

Place and Cause of Death in Centenarians: A Population-Based Observational Study in England, 2001 to 2010

Background

Centenarians are a rapidly growing demographic group worldwide, yet their health and social care needs are seldom considered. This study aims to examine trends in place of death and associations for centenarians in England over 10 years to consider policy implications of extreme longevity.

Methods and Findings

This is a population-based observational study using death registration data linked with area-level indices of multiple deprivations for people aged ≥100 years who died 2001 to 2010 in England, compared with those dying at ages 80-99. We used linear regression to examine the time trends in number of deaths and place of death, and Poisson regression to evaluate factors associated with centenarians’ place of death. The cohort totalled 35,867 people with a median age at death of 101 years (range: 100–115 years). Centenarian deaths increased 56% (95% CI 53.8%–57.4%) in 10 years. Most died in a care home with (26.7%, 95% CI 26.3%–27.2%) or without nursing (34.5%, 95% CI 34.0%–35.0%) or in hospital (27.2%, 95% CI 26.7%–27.6%). The proportion of deaths in nursing homes decreased over 10 years (−0.36% annually, 95% CI −0.63% to −0.09%, p = 0.014), while hospital deaths changed little (0.25% annually, 95% CI −0.06% to 0.57%, p = 0.09). Dying with frailty was common with “old age” stated in 75.6% of death certifications. Centenarians were more likely to die of pneumonia (e.g., 17.7% [95% CI 17.3%–18.1%] versus 6.0% [5.9%–6.0%] for those aged 80–84 years) and old age/frailty (28.1% [27.6%–28.5%] versus 0.9% [0.9%–0.9%] for those aged 80–84 years) and less likely to die of cancer (4.4% [4.2%–4.6%] versus 24.5% [24.6%–25.4%] for those aged 80–84 years) and ischemic heart disease (8.6% [8.3%–8.9%] versus 19.0% [18.9%–19.0%] for those aged 80–84 years) than were younger elderly patients. More care home beds available per 1,000 population were associated with fewer deaths in hospital (PR 0.98, 95% CI 0.98–0.99, p<0.001).

Conclusions

Centenarians are more likely to have causes of death certified as pneumonia and frailty and less likely to have causes of death of cancer or ischemic heart disease, compared with younger elderly patients. To reduce reliance on hospital care at the end of life requires recognition of centenarians’ increased likelihood to “acute” decline, notably from pneumonia, and wider provision of anticipatory care to enable people to remain in their usual residence, and increasing care home bed capacity. Please see later in the article for the Editors'' Summary     

School Performance and the Risk of Suicidal Thoughts in Young Adults: Population-Based Study

Although low school performance is related to attempted and completed suicide, its relationship with suicidal thoughts has been less clear. We conducted a population-based study including 10081 individuals aged 18–29 years in Stockholm, Sweden, and found a clear positive gradient in the risk of lifetime suicidal thoughts with decreasing levels of compulsory school leaving grades. This relationship was somewhat attenuated but remained significant in multivariate models accounting for family background, severe adult psychopathology and adult socioeconomic conditions. School failure is associated with an increased risk of experiencing suicidal thoughts and may also increase the tendency of acting upon them.     

Awareness of Climate Change and the Dietary Choices of Young Adults in Finland: A Population-Based Cross-Sectional Study

Climate change is a major public health threat that is exacerbated by food production. Food items differ substantially in the amount of greenhouse gases their production generates and therefore individuals, if willing, can mitigate climate change through dietary choices. We conducted a population-based cross-sectional study to assess if the understanding of climate change, concern over climate change or socio-economic characteristics are reflected in the frequencies of climate-friendly food choices. The study population comprised 1623 young adults in Finland who returned a self-administered questionnaire (response rate 64.0%). We constructed a Climate-Friendly Diet Score (CFDS) ranging theoretically from −14 to 14 based on the consumption of 14 food items. A higher CFDS indicated a climate-friendlier diet. Multivariate linear regression analyses on the determinants of CFDS revealed that medium concern raised CFDS on average by 0.51 points (95% confidence interval (CI) 0.03, 0.98) and high concern by 1.30 points (95% CI 0.80, 1.80) compared to low concern. Understanding had no effect on CFDS on its own. Female gender raised CFDS by 1.92 (95% CI 1.59, 2.25). Unemployment decreased CFDS by 0.92 (95% CI −1.68, −0.15). Separate analyses of genders revealed that high concern over climate change brought about a greater increase in CFDS in females than in males. Good understanding of climate change was weakly connected to climate-friendly diet among females only. Our results indicate that increasing awareness of climate change could lead to increased consumption of climate-friendly food, reduction in GHG emissions, and thus climate change mitigation.     

Increased Risk of Ischemic Stroke in Young Patients with Ankylosing Spondylitis: A Population-Based Longitudinal Follow-Up Study

Background

Prospective data on the association between ischemic stroke and ankylosing spondylitis (AS) in the young are sparse. The purpose of this population-based, age- and sex-matched longitudinal follow-up study was to investigate the risk of developing ischemic stroke in young patients with AS.

Methods

A total of 4562 patients aged 18- to 45-year-old with at least two ambulatory visits in 2001 with a principal diagnosis of AS were enrolled in the AS group. The non-AS group consisted of 22810 age- and sex-matched, randomly sampled subjects without AS. The two-year ischemic stroke-free survival rate for each group were calculated using the Kaplan-Meier method. Cox proportional hazards regression analysis was used to estimate the hazard ratio of ischemic stroke after adjusting for demographic and clinical covariates.

Results

During follow-up, 21 patients in the AS group and 53 in the non-AS group developed ischemic stroke. The ischemic stroke-free survival rate over the 2 year follow-up was lower in the AS group than the non-AS group (p = 0.0021). The crude hazard ratio of ischemic stroke for the AS group was 1.98 (95% CI, 1.20–3.29; p = 0.0079) and the adjusted hazard ratio after controlling for demographic and comorbid medical disorders was 1.93 (95% CI, 1.16–3.20; p = 0.0110).

Conclusion

Our study showed an increased risk of developing ischemic stroke in young patients with AS.     

The Health Care Cost of Dying: A Population-Based Retrospective Cohort Study of the Last Year of Life in Ontario,Canada

Background

Coordinated and appropriate health care across sectors is an ongoing challenge, especially at the end-of-life. Population-level data on end-of-life health care use and cost, however, are seldom reported across a comprehensive array of sectors. Such data will identify the level of care being provided and areas where care can be optimized.

Methods

This retrospective cohort study identified all deaths in Ontario from April 1, 2010 to March 31, 2013. Using population-based health administrative databases, we examined health care use and cost in the last year of life.

Results

Among 264,755 decedents, the average health care cost in the last year of life was $53,661 (Quartile 1-Quartile 3: $19,568-$66,875). The total captured annual cost of $4.7 billion represents approximately 10% of all government-funded health care. Inpatient care, incurred by 75% of decedents, contributed 42.9% of total costs ($30,872 per user). Physician services, medications/devices, laboratories, and emergency rooms combined to less than 20% of total cost. About one-quarter used long-term-care and 60% used home care ($34,381 and $7,347 per user, respectively). Total cost did not vary by sex or neighborhood income quintile, but were less among rural residents. Costs rose sharply in the last 120 days prior to death, predominantly for inpatient care.

Interpretation

This analysis adds new information about the breadth of end-of-life health care, which consumes a large proportion of Ontario’s health care budget. The cost of inpatient care and long-term care are substantial. Introducing interventions that reduce or delay institutional care will likely reduce costs incurred at the end of life.     

Initial Trends of Bird Assemblages Before and After River Diversion in an Endemic-rich African Forest

The Lower Kihansi Hydropower Project in southern Tanzania caused the diversion of the Kihansi River from the Kihansi Gorge in the year 2000. By sampling the understorey avifauna prior to diversion, we examined (i) whether the adjacent Udagaje Gorge was an adequate control for observations in the Kihansi Gorge; (ii) which species of conservation interest occurred; and, (iii) which season best suited annual monitoring. Species composition and capture rates at three and two elevational transects in the Kihansi Gorge and Udagaje Gorge, respectively, confirmed that Udagaje had a comparable avifaunal assemblage to Kihansi. The cold season was most appropriate for population monitoring because >2 times more individuals were captured in the cold than hot season at both gorges, and at least four altitudinal migrants were present in the cold but not hot season. Post-diversion sampling revealed that only the Upper Kihansi transect suffered a significant decrease in number of individuals, a result that was driven largely by a decline in the Little Greenbul, Andropadus virens. This transect is closest to the Kihansi waterfall and associated spray zone which were lost after river diversion. Lack of differences in bird communities at other transects after diversion illustrates that early post-diversion effects on birds are probably concentrated near the base of the main falls. Together with studies of other biota in Kihansi, we propose that long-term monitoring is necessary to understand the factors that regulate changes in species composition of this threatened forest site.     

The Relationship between Alcohol Outlets,HIV Risk Behavior,and HSV-2 Infection among South African Young Women: A Cross-Sectional Study

BackgroundAlcohol consumption has a disinhibiting effect that may make sexual risk behaviors and disease transmission more likely. The characteristics of alcohol-serving outlets (e.g. music, dim lights, lack of condoms) may further encourage risky sexual activity. We hypothesize that frequenting alcohol outlets will be associated with HIV risk.MethodsIn a sample of 2,533 school-attending young women in rural South Africa, we performed a cross-sectional analysis to examine the association between frequency of alcohol outlet visits in the last six months and four outcomes related to HIV risk: number of sex partners in the last three months, unprotected sex acts in the last three months, transactional sex with most recent partner, and HSV-2 infection. We also tested for interaction by alcohol consumption.ResultsVisiting alcohol outlets was associated with having more sex partners [adjusted odds ratio (aOR), one versus zero partners (95% confidence interval (CI)): 1.51 (1.21, 1.88)], more unprotected sex acts [aOR, one versus zero acts (95% CI): 2.28 (1.52, 3.42)], higher levels of transactional sex [aOR (95% CI): 1.63 (1.03, 2.59)], and HSV-2 infection [aOR (95% CI): 1.30 (0.88, 1.91)]. In combination with exposure to alcohol consumption, visits to alcohol outlets were more strongly associated with all four outcomes than with either risk factor alone. Statistical evidence of interaction between alcohol outlet visits and alcohol consumption was observed for all outcomes except transactional sex.ConclusionsFrequenting alcohol outlets was associated with increased sexual risk in rural South African young women, especially when they consumed alcohol. Sexual health interventions targeted at alcohol outlets may effectively reach adolescents at high risk for sexually transmitted infections like HIV and HSV-2.

Trial Registration

HIV Prevention Trials Network HPTN 068